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Date of visit 21 January 2019 Level(s) FY, CMT, ST3+

Type of visit Re-visit Hospital Royal Infirmary of Edinburgh at

Little France

Specialty(s) General Internal Medicine Board NHS Lothian

Visit panel

Dr Alastair McLellan Visit Chair – Postgraduate Dean for Quality

Dr Alan McKenzie Quality Lead – Associate Postgraduate Dean for Quality

Dr Reem AlSoufi Quality Lead – Associate Postgraduate Dean for Quality

Dr Ben Chadwick College Representative (Acute Medicine)

Dr Jessie Sohal-Burnside Trainee Associate

Ms Jan Lyell Lay Representative

Ms Heather Stronach Quality Improvement Manager

In attendance

Ms Claire Rolfe Quality Improvement Administrator

Specialty Group Information

Specialty Group

Medicine

Lead Dean/Director

Professor Alastair McLellan

Quality Lead(s) Dr Reem Al-Soufi

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Dr Stephen Glen

Dr Alan McKenzie

Quality Improvement

Manager(s)

Heather Stronach and Alex McCulloch

Unit/Site Information

Non-medical staff in

attendance

4 non-medical staff

Trainers in attendance 5 consultants

Trainees in attendance 19 trainees 7 FY, 5 CMT, 1 ACCS, 6 ST

Feedback session:

Managers in attendance

Service Managers and consultant physicians

Date report approved by

Lead Visitor

20/03/2019

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1. Principal issues arising from pre-visit review

Following review and triangulation of available data, including the General Medical Council’s

(GMC’s) National Training Survey (NTS) and the Deanery’s Scottish Trainee Survey (STS), a

Deanery re-visit was arranged to general internal medicine (GIM) at the Royal Infirmary of

Edinburgh (RIE) at Little France.

The last Deanery visit to the RIE took place on 18 January 2017.

Areas found to be working well at the 2017 Deanery visit were:

• consultant support

• formal teaching offered

• front door experience

• ward experience with good supervision and a high frequency of consultant ward rounds

• acute medical unit (AMU) handover was safe and thorough

• consultant support for registrars in clinics

• managing adverse incidents/Datix reporting

• GIM teaching organised by registrars and efforts to improve GIM teaching

• induction was improving, with content becoming more relevant to the trainees.

Areas working less well at the 2017 Deanery visit were:

Primary assessment area:

• The management and clinical leadership structure of the area did not feel safe to trainees.

Trainees had no ability to know where their patients were or how well they were. There had

been one incident of inappropriate pressure on a trainee to undertake a less robust

assessment to move patients through the area.

• Primary assessment area evening handover: Clarity is required regarding who staff should

handover to in the evening, e.g. the hospital at night (HaN) team or accident and

emergency (A&E).

Foundation year experience:

• Non-educational tasks for foundation year 1 trainees.

• Pressure to discharge patients for foundation year 1 and 2 trainees.

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• Phlebotomy access: foundation year trainees reported limited and inconsistent phlebotomy

support (although four phlebotomists had recently been appointed and were due to start

work).

• Rota gaps: Trainees were not aware if any effort had been made to cover gaps in rota due

to sick leave, including leave that was known about in advance.

• Initial educational supervisor meeting: Several foundation year doctors were still to meet

their educational supervisors and did not have learning agreements in place.

Core and General Practice Specialty Trainees (GPST):

• Access to teaching and core and GPST had not attended any general medical clinics since

starting their post and felt unable to meet their curricular requirements.

Higher trainee experience:

• Clinical supervision and feedback: Clarity was required regarding which consultant was

responsible for supporting the registrar holding the 4110 bleep. Further options could be

explored to enable feedback for higher trainees following a HaN shift and to attend post-

take ward rounds.

• Weekend staffing and workload: higher trainees reported the number of wards and thus

patients they had to cover whilst on the weekend raising patient safety concerns.

• Decisions to board patients and the tracking of them: the medical team’s involvement in

these decisions did not always appear to be considered. A policy was being developed to

guide this process. The panel heard of whiteboards being used to track boarded patients

instead of the el TRAK.

• HaN morning handover: the foundation year 1 trainee attended the HaN handover and

passed on this information to the more senior staff. The foundation year 1 trainee had no

knowledge of the patients being discussed and the registrars working HaN shifts received

no feedback about their work.

• Induction: clarity on roles and responsibilities and geographical orientation was required.

Trainees starting on nights needed to receive induction.

• Night rota, staffing and HaN role: clarity and implementation was required regarding what

responsibility HaN had for ‘front door’ patients and how to manage if trainees were needed

in both the back wards and front door.

• Use of the term SHO.

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As part its national review of Scotland, the GMC also visited the RIE on 5 and 6 October 2017.

The full GMC report can be found here: https://www.gmc-uk.org/-/media/documents/gmc-

national-review---nhs-lothian-report_pdf-74411060.pdf

The following data was collected and analysed prior to the January 2019 Deanery re-visit:

• NTS 2018 = National Training Survey (2018)

• PVQ = Pre-visit Questionnaire (2018)

• STS = Scottish Training Survey (2018).

According to trainee responses from these most recent data sources, areas that may require

improvement are illustrated in the table below:

Issue Post data

Adequate Experience

Clinical Supervision +OOH NTS, PVQ

Educational Supervision PVQ

Feedback NTS

Handover STS, PVQ

Induction NTS, PVQ

Patient Safety

Teaching (formal) NTS

Workload/Working Hours STS, PVQ

Study Leave

Team Culture

Environment/Undermining

Learning from adverse incidents PVQ

Educational Governance

Overall Satisfaction

2. Introduction

The RIE is a major acute teaching hospital in Edinburgh. It has a 24-hour accident and

emergency department, and provides a full range of acute medical and surgical services for

patients from across Lothian. As well as specialist services for people from across the south

east of Scotland and beyond. During the visit the panel met with trainers and trainees involved

in the GIM programme and non-medical staff working in the same locations. All the RIE

trainees from GIM are based in the following locations: the ‘back wards’ - wards 207 and 208,

the ‘front door’ or combined assessment unit which comprises the primary assessment area,

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ambulatory care and the AMU. Whilst some trainees were currently in a parent specialty

posting they were directed to provide feedback only on their time as a GIM trainee at RIE.

A summary of the discussions has been compiled under the headings in section 3 below. This

report is compiled with direct reference to the GMC’s Promoting Excellence - Standards for

Medical Education and Training. Each section heading includes numeric reference to specific

requirements listed within the standards.

The panel met with trainers and non-medical staff as well as the following groups: foundation

year trainees (FY), core medicine trainees (CMT), and an acute care common stem (ACCS)

trainee working in acute medicine, and specialty training registrars (STs) working in general

internal medicine.

3.1 Induction (R1.13)

Trainers: Trainers advised there is a structured induction programme. An NHS Lothian wide

induction takes place once a year in August which comprises:

• a general overview of the geography of the hospital

• how the rotas work and when these are issued

• how each clinical area and their teams work (for example, the interface team, the AMU

team, the ward-based teams and the HaN teams).

Trainees are sent a copy of the induction materials by email and receive information about

security access cards and access for IT systems.

If trainees are unable to attend their normal inductions, trainers advised that much of the same

information is also available on the intranet. For trainees starting on nights, there is the

opportunity for them to meet with the HaN team prior to starting work.

Trainers stated that trainees appear to be satisfied with induction and that induction is a

continuous work in progress based on feedback from trainees. As trainees work in a variety of

areas and have different responsibilities, the aim for the future is to provide this information in

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‘bitesize chunks’ on the intranet so that trainees can access the information they readily need

regarding the roles and responsibilities for their respective roles.

FY: Most foundation trainees confirmed receiving the NHS Lothian wide induction. It

highlighted to them what was expected within the first week. Trainees could recall receiving

information about toxicology and the differences in prescribing between Scotland and England.

They also received Trakcare training.

FY trainees said that hospital induction was good. Trainees appreciated being able to

familiarise themselves with the colleagues they would be working with. A catch-up induction did

not appear to be arranged for those who missed hospital induction due to starting on nights or

being on annual leave.

Trainees confirmed receiving induction materials by email. However, they were frustrated that

they were unable to access some of the information links available within the induction

document as this required access to the intranet (trainees were not permitted access to the

intranet at this stage prior to starting work at the RIE).

Trainees said there was a specific AMU induction explaining the different start times of the job

and the expected roles of colleagues. They were taken on a tour of the department and were

shown where to find equipment. Trainees expressed frustration that their individual codes for

the arterial-blood gas (ABG) machine did not work. Despite being told that this was resolved,

trainees told the visiting panel that most were still unable to use their own codes.

CMT and ACCS: CMT and ACCS trainees also confirmed an NHS Lothian wide hospital

induction. Some trainees had not attended hospital induction because they had already worked

in NHS Lothian within the last 2 years (trainees who have attended the hospital induction within

the last 2 years are not required to attend it again).

This cohort of trainees was also perplexed that they could not access the information links

within the induction document because it required intranet access and were also frustrated by

the problems with access to the ABG machine.

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Trainees felt strongly that the system for obtaining swipe card access could be better

coordinated. They felt that standing in long queues was an inefficient use of time and trainees

could be asked to attend at specific times during the day to ease the flow.

Trainees said induction could be improved by signposting to them what competencies they can

achieve during the placement (as it is for FY trainees) in addition to a departmental induction

that included a tour of the department.

ST: ST trainees highlighted the same issues with induction as previous cohorts. One trainee

did not receive the induction materials by email.

ST trainees thought that induction could be improved with a better outline on the roles and

responsibilities for a medical registrar.

Non-Medical Staff: Non-medical staff said that induction prepares trainees well for starting at

the RIE – ‘they get a good overview of the hospital’.

3.2 Formal Teaching (R1.12, 1.16, 1.20)

Trainers: Trainers said there is an array of local teaching opportunities at the RIE including:

• Monday lunchtime teaching (1 hour weekly)

• Tuesday FY teaching

• Thursday journal club (1 hour fortnightly)

• Friday lunchtime multi-disciplinary team teaching (1 hour weekly)

• Simulation training (fortnightly)

• Imaging meetings (on average one per month).

• Other – mastery skills programme

The Monday lunchtime teaching focuses on topics pertaining to patient safety such as

prescribing, requesting clinical diagnostic tests (imaging, blood tests etc) defibrillation and Datix

reporting, whereas the Friday teaching focuses on clinical teaching.

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Simulation training is in its infancy. The aim is to deliver simulation training on a fortnightly

basis and bring it to the wards. Examples topics of simulation training include the top twenty

emergency presentations matched to the CMT curriculum, for example acute kidney injury.

All health professionals, not just doctors, are encouraged to take part in this simulation training.

This ensures that each person is aware of their role and responsibilities in dealing with an

emergency as enacted by the simulation. The health board plans to use simulation training to

learn about human factors as well and there is an intention to incorporate learning from

incidents reported through the Datix system to create scenarios that are based on real life

cases.

Trainees must register electronically to take part in simulation training. This means feedback

can be sought from participants to ensure the continuous improvement of simulation training

and that the training delivered is relevant to the real-life practices of the hospital. On completion

of the training, an electronic certificate is generated for participants which outlines the

competencies achieved by the training so that this may be added to a trainee’s electronic

portfolio to evidence their learning in this practice area.

The mastery skills programme is to teach clinical skills (such as lumbar puncture and knee joint

aspiration) to doctors in training below ST3 level, and has defined faculty that includes

consultant trainers.

Trainers confirmed that local teaching for trainees is not bleep free. One proposal for making it

bleep free was to upskill advanced nurse practitioners to allow them to hold the bleeps while

teaching takes place.

Foundation trainees have a formal hospital wide teaching programme and are released from

clinical duties to attend this teaching. The only trainees unable to attend this teaching are those

rostered to work on nights or who are on annual leave.

FY: Foundation trainees confirmed the formal hospital teaching timetable as described on page

8. On average, most FY1 trainees had attended four sessions since August. Only two out of

eight FY1 trainees had attended simulation training so far. Foundation trainees expressed the

view that ‘when working on acute take on AMU it is impossible to leave to attend teaching.’

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Trainees felt the rota pattern was not conducive to attending formal teaching opportunities and

several trainees described coming in on their day off to attend teaching.

CMT and ACCS: CMT and ACCS trainees also confirmed the hospital teaching timetable. On

average, these trainees had attended just 1 hour of teaching per week and none of the trainees

we spoke to had been able to attend the simulation training so far (but this had only just started

by the time of this visit). Like FY trainees, this cohort of trainees described workload and rota

design as barriers to attending teaching.

There is no local CMT-oriented teaching. If this were offered, trainees think this would improve

their training experience. Trainees would also like provision of local support for their

preparation for the Membership of the Royal College of Physicians - Practical Assessment of

Clinical Examination Skills (PACES) exam.

ST: On average ST trainees had attended 2 hours of teaching per week. One ST trainee said

there had been a lot of endocrinology and diabetes teaching on Fridays and would like to see

other specialties in future.

There are six regional training days per year for STs. All trainees can attend regional teaching

unless they are the person rostered to be on call.

Non-Medical Staff: Non-medical staff said that they support trainees to attend their formal

teaching sessions and try to support it being bleep free. They said that trainees are only called

back in medical emergencies.

3.3 Study Leave (R3.12)

Trainers: Trainers said that trainees are asked to book study leave as far in advance as

possible. There is a blank rota where trainees can pick the rota slots they prefer, and the health

board tries to allocate trainees one of their top three choices. Study leave is facilitated as far as

possible and sometimes trainees can arrange their own swaps with colleagues.

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Trainees: Trainees said it is easy for them to request and take study leave if they are on a

normal day shift. Taking study leave is more difficult if they are on the on take rota, or on

nights, but they are able to do so if they can organise cover.

3.4 Formal Supervision (R1.21, 2.15, 2.20, 4.1, 4.2, 4.3, 4.4, 4.6)

Trainers: Educational and clinical supervisors are allocated to trainees based on what team

they are working in. In the past, trainers might have had two trainees of different grades

allocated to them (for example FY and CMT), but this meant that trainers had to be cognisant

of the two different curricula required for these training grades. The Clinical Director now

allocates just one type of training grade to trainers.

Trainers are allocated to trainees 6 weeks in advance of them starting in post. When there are

known concerns about a trainee, these would usually come to the head of department (HoD).

The HoD, together with the training programme director (TPD) and the educational supervisor

(ES), will discuss how to best support the trainee and will decide whether any additional

support, such as higher-level supervision, may be required.

Each trainer has 0.25 ‘supporting professional activity’ (SPA) sessions per trainee in their job

plan to provide educational supervision. Each educational supervisor has a maximum of four

trainees assigned to them. All educational supervisors complete the Recognition of Trainers as

part of their appraisal process and have completed the Clinical Education Programme (CEP)

Level 2 training. Educational supervisors change at each rotation.

All trainees: All trainees (but one) confirmed having educational supervision and did not raise

any concerns regarding supervision.

Non-Medical Staff: Non-medical staff consider that doctors in training can always access

senior support.

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3.5 Adequate Experience (opportunities) (R1.15, 1.19, 5.9)

Trainers: Trainers said that trainees get a good general medicine experience at the RIE.

Trainees observe the full assessment of a patient including taking a patient’s history, ordering

investigations, devising a treatment plan and managing patients until the condition is stabilised.

Trainers are aware of the various curricula requirements for trainees.

To ensure trainees attend a satisfactory number of clinics, trainers are introducing the role of a

rota master to create a rostering system for clinics. The ambulatory care experience at the RIE

does not currently qualify as a supervised clinic; however, trainers are exploring what might be

done to allow it to meet the criteria.

When asked which curriculum competencies or learning outcomes might be more difficult for

trainees to achieve, trainers said that some procedures (for example chest drains) can be more

difficult. Consultant physician, Dr James Tiernan, has introduced a Mastery Skills Programme

to ensure that trainees achieve their procedural competencies (for example, chest drains,

central lines and lumbar puncture). This is supported by faculty comprising consultant trainers

within RIE.

Trainers said that trainees may consider that the process for prescribing is laborious and some

FYs may feel that they spend too much time writing discharge summaries.

STs are ward based and are split into two teams, the Reg 207 team and the Reg 208 team.

STs also get one session a week to maintain experience in their area of specialty expertise.

FY: FY trainees consider that their training experience is good. One trainee described it as ‘one

of the most wide-ranging training experiences I have ever had.’ They consider that their clinical

experience within AMU is better than what they would achieve if they were based on the wards.

Trainees also particularly enjoyed ‘interface’ shifts where they get to experience GP referrals to

A&E.

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When asked if there were any competencies that were difficult to achieve, trainees agreed that

the opportunity to draw up fluids and have this competency signed off can be limited, especially

when working nights. One trainee described their experience at another hospital where a nurse

educator organises group sessions with trainees to cover such aspects of training. Trainees

considered that the RIE could benefit from adopting a similar approach. However, the ability to

access teaching is their main concern for this post.

CMT and ACCS: This cohort was also satisfied with their experience of working in AMU and

the training experiences it offers. CMT trainees were concerned about their access to clinics. It

is expected that they attend at least 7/8 clinics per 4-month block to meet their curriculum

requirements; current access to clinics was described as ‘few and far between’. It was noted

that a rota to schedule clinic attendance has been introduced, but this had not so far enabled

the clinic attendance target to be met due to rota pressures.

Clinics are advertised ‘on the wall’ and are emailed out to trainees so trainees are aware of

what clinics are available, but workload prevents them from attending.

It was noted that a process of rostering CMTs to clinics has been introduced but is in its infancy

– and thus far has not rostered sufficient clinics to meet their needs.

ST: ST trainees said there is frequent opportunity for consultant led ward rounds. One trainee

felt that knee aspiration might be difficult to achieve for their curriculum and suggested that this

could be covered by a skills lab session.

ST trainees have clinics built within their rotas. On average, ST trainees are attending 2

general medicine clinics per month.

3.6 Adequate Experience (assessment) (R1.18, 5.9, 5.10, 5.11)

Trainers: Trainers said that working within AMU, there are plentiful opportunities for trainers to

complete the acute care assessment tool (ACATs) for CMT trainees as part of their

assessment.

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STs are primarily based on the wards. Feedback from previous STs was that they do not get

enough experience in AMU meaning that ACAT assessments were difficult to achieve. STs

now have allocated time within AMU where they work with the consultant on the acute take and

this has resolved the difficulty around achieving ACAT assessments for ST trainees.

FY: FYs said it is easy for them to complete the assessments required of them and

assessments are fair. They found it reassuring at induction to hear that they should be able

achieve sign off for all of the components required for their curriculum.

CMT and ACCS: Trainees said they need to be proactive, but they can achieve the

assessments required.

ST: ST trainees said, ‘it is easier here than in other places’ to achieve the assessments

required, for example, they can do mini-clinical evaluations (Mini-cex) on ward rounds and

ACATs in AMU.

Non-Medical Staff: Non-medical staff contribute to the assessment of doctors in training via

the multi-source feedback tool.

3.7 Adequate Experience (multi-professional learning) (R1.17)

Trainers: Trainers stated that Friday lunchtime teaching was an opportunity for multi-

professional learning. Consultants from different teams deliver this teaching based on their

specialty area. Examples given were: teaching on acute heart failure by a consultant

cardiologist; teaching on how to handle endocrine emergencies by endocrinology and diabetes’

consultants; and, neurologists teaching about stroke. Feedback from trainees about these

sessions had been very positive. Trainees have said that it improves their confidence about

what to look out for on the first assessment of a patient and it also helps them to write referral

letters to consultants.

Trainees: Trainees recognised the Friday lunchtime teaching as a multi-disciplinary learning

experience and also mentioned the multi-professional simulation-based training.

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Non-Medical Staff: Non-medical staff confirmed that nurses are invited to attend the weekly

Friday teaching sessions.

3.8 Adequate Experience (quality improvement) (R1.22)

Trainers: Trainers said that audit projects are available online. Trainees are also emailed a

spreadsheet listing potential quality improvement projects. If a trainee has a particular interest,

they are able to pursue this on discussion and agreement with their educational supervisor.

Trainees can present their findings at poster meetings.

Trainees: All trainees confirmed that there are opportunities to engage in quality improvement

projects or audit.

3.9 Clinical supervision (day to day) (R1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 2.14, 4.1, 4.6)

Trainers: Discussion about trainees takes place at consultant meetings to ensure that trainees

are well supported and appropriately supervised according to their level of training. Trainers

advised that there is a very clear escalation process and this is made clear at induction so

trainees should feel well supported both during the day and out of hours. There is a designated

senior colleague readily available on call at night.

Trainers are not aware of instances where trainees have had to cope with problems that were

beyond their experience or competence.

FY: FYs feel well supported and like the system adopted within general medicine at the RIE of

having foundation year 1 doctors buddied on the rota with a foundation 2 or CMT trainee. All

FYs confirmed that they have never felt they have had to cope with problems out with their

competence or experience. There is always senior support available.

CMT and ACCS: Trainees reported no issues in terms of clinical supervision.

ST: ST trainees also confirmed that they have satisfactory clinical supervision.

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Non-Medical Staff: Non-medical staff said that trainees introduce themselves and staff know

them well so are aware of their different levels of experience and training. They know. ‘what

can be done and by whom’.

The non-medical staff we met did not recognise that coloured badges worn by doctors is a way

to identify doctors at different levels of training. Non-medical staff believed the colour coding

referred to the team the doctors are based in.

3.10 Feedback to trainees (R1.15, 3.13)

Trainers: Trainers said that trainees get day to day feedback - although they considered that it

may not always be recognised as feedback by trainees. They said that CMT trainees will

recognise the feedback they get at clinic. CMT trainees lead the consultation and the

supervising consultant always provides feedback to trainees at the end of consultation.

FY: FYs said, ‘if you are willing to ask for feedback, you will receive it.’

CMT and ACCS: This cohort of trainees said that the amount of feedback received was

variable and depends on the consultant. However, trainees were confident that if a trainee felt

they were struggling they would be able to ask for, and receive, more regular feedback.

Trainees felt they would benefit from more frequent feedback in particular to inform their

learning in relation to their input to the management of acute medical cases. Feedback when

working nights was felt to be scant.

ST: ST trainees said they receive feedback during ward rounds. They also appreciate the

experience of mimicking the consultant on the acute take in AMU and the feedback they

receive from this experience.

3.11 Feedback from trainees (R1.5, 2.3)

Trainers: Trainers said they receive informal feedback from trainees during their placement

and can receive feedback from the Deanery at the end of training via the trainee’s annual

review of competence progression process. Trainers recognised that there is no formal

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mechanism in place at the hospital in which trainees can feedback about their training. They

are exploring implementing a junior doctor forum, and also a wellbeing forum where trainees

can reflect on practice. Neither of these have yet come to fruition.

FY: FY trainees said that the buddying system meant that there was frequent opportunity to

share ideas. They were not aware of any forum in which they could provide feedback to

trainers and the management team on the quality of their training.

CMT and ACCS: These trainees were unaware of any opportunities to provide feedback on

their training.

ST: ST trainees said they would feed back to their educational supervisor if they had any

training concerns they wished to raise. They also mentioned a recent survey by Dr Caroline

Bates asking trainees for feedback about three things they like and three suggestions to

improve the training experience at the RIE.

3.12 Workload/ Rota (1.7, 1.12, 2.19)

Trainers: Trainers said they have tried to build team working within shift-based rotas via the

buddying system. The FY1s and either FY2s or CMTs are scheduled to work together on the

same shift pattern to provide familiarity and improve support for junior staff.

FY: FYs consider that their workload is busy but manageable. Staffing varies and working out

of hours always appears to be understaffed. They felt that cover over the Christmas period was

suboptimal. Senior support was provided by a locum doctor who had not previously worked

within NHS Lothian and needed assistance with IT systems such as Trakcare.

Trainees were generally happy with the rota and the ability to choose their preferences. They

said that the rota is updated on the intranet. Aside from a few administrative glitches, such as

not being notified of a rota change, they were generally happy with how the rota is

administrated.

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CMT and ACCS: This cohort said that their workload workload was very heavy enabled little,

limiting flexibility and limited access to training opportunities.

ST: ST trainees said that their workload felt manageable both during the day and out of hours.

In AMU, the ‘interface registrar’ used to hold the on-call bleep but now this responsibility of

someone in A&E and this feels much safer for trainees.

ST trainees felt that there may be benefit having trainee involvement in the organisation of the

rotas.

Non-Medical Staff: Non-medical staff recognised that the workload was busy. The board tried

to fill any rota gaps with locum positions to ease the burden on staff. Non-medical staff told the

visiting panel that the rota goes to the compliance board before it is issued to trainees.

3.13 Handover (R1.14)

Trainers: In AMU there is a handover first thing in the morning and a 9pm handover to the HaN

team. Handover is consultant led and takes place verbally where they run through the patient

list on the board. Trakcare is also used to provide a written record of the handover of patients’

care. There is also a formal handover meeting held on Friday to cover the weekend ahead.

FY: Handovers are perceived to be safe and effective and occur in the last 30 minutes of their

12 hours shifts. They are generally consultant-led but we heard about inconsistencies among

different consultants as to how and where handovers are conducted. Handover following night

shift feels inefficient with trainees reporting that it can last 45 minutes longer than planned.

Handovers can provide learning opportunities. Trakcare is used to record and support

handovers.

CMT and ACCS: This cohort said that handovers support safe care. They also confirmed

details of handover being entered into Trakcare. These trainees also felt that the structure to

handovers could be improved to be of more educational benefit to trainees.

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ST: ST trainees said that the 9pm main handover to the HaN team on the wards is structured

and is led by a senior HaN nurse practitioner handing over to the medical registrar working on

nights. There is also an end of shift handover at 10pm. In the morning there is a handover from

HaN to the day team. Handovers are all logged via Trakcare. Handovers support safe patient

care.

Non-Medical Staff: Non-medical staff echoed the comments made by doctors in training. They

said that handover works well and the nursing team are always at handover. Non-medical staff

acknowledged that how handover is done is not consistent across the teams / wards; however,

the perception is that handover is safe.

3.14 Educational Resources (R1.19)

FY: FY trainees raised no concerns about educational resources.

CMT and ACCS: This cohort said it would be ideal if they could have allocated time dedicated

within their rotas to dictate discharge letters and a separate space available for them to do so.

ST: ST trainees would appreciate a dedicated registrars’ room.

Overall, trainees felt that computer access for administrative duties is inadequate.

3.15 Support (R2.16, 2.17, 3.2, 3.4, 3.5, 3.10, 3.11, 3.13, 3.16, 5.12)

It was clear to the visiting panel that reasonable adjustments (for example, not starting on

nights) had been made for trainees returning to work following an absence from clinical

practice. Trainees were unsure whether consultants were aware which trainees may have been

on career breaks and the possible need to provide increased support. Trainees were also

unsure whether planned supernumerary periods were as effective as intended due to the

challenges around a busy workload and feeling the need to ‘muck in.’

Non-Medical Staff: Non-medical staff said that if the performance of a trainee raised potential

concerns about patient care, they would raise this with the lead consultant of the department or

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a trainee’s educational or clinical supervisor. They were confident that matters of additional

support would be handled appropriately.

3.16 Educational governance (R1.6, 1.19, 2.1, 2.2, 2.4, 2.6, 2.10, 2.11, 2.12, 3.1)

Trainees were not aware how the quality of their education and training at the RIE is managed.

3.17 Raising concerns (R1.1, 2.7)

Trainees: Trainees said that they would raise any concerns with senior colleagues. They were

aware of the escalation procedures around this as this was made explicit at induction. No

trainees would feel uncomfortable raising concerns.

Non-Medical Staff: Non-medical staff would be comfortable raising concerns. They would do

so with the lead consultant, clinical director or change nurse, dependent on the nature of the

concern and who would be most appropriate person to refer the concern to.

3.18 Patient safety (R1.2)

Trainers: Trainers talked about Monday mortality and morbidity (M+M) meetings where any

Datix cases are discussed. It is a ‘safe space’ to talk about any patient safety concerns.

Trainers said that patient safety is always the primary concern.

Trainees are informed at induction to escalate any concerns about patient safety to a

consultant. If a trainee considers that any concerns raised have not been dealt with

satisfactorily by the consultant, they should raise it to the Clinical Director.

Trainees: Doctors in training regarded this training environment as safe. They commended, in

general, safety within the AMU however flagged two concerns: a) the lack of a system that

provided an overview of the whole acute medicine workload, and b) the lack of a triage system

that ensured the most unwell patients in AMU would be prioritised for assessment and

management by the medical team. We heard also that when patients come into the AMU from

A&E - a management plan may been put in place but not initiated within A&E and this was

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perceived to cause delays in treatment within AMU which had potential to impact on patient

safety.

There was acknowledgement that patients who are boarded out do not get the same quality of

care as patients who are managed in their own specialties’ wards. We heard their perception

that occasionally inappropriate patients are boarded and that frustrations can be expressed

about boarding of patients. At times there is ambiguity over who the responsible consultants

and team responsible for the care of boarded patients are. Trakcare is reported to list the name

of the admitting consultant, who may not have ongoing responsibility for care.

Non-Medical Staff: Non-medical staff said they help support a safe environment through

safety huddles and have no concerns about patient safety.

3.19 Adverse incidents (R1.3)

Adverse incidents are recorded in Datix. All trainees were aware of Datix.

3.20 Duty of candour (R1.4)

It was clear to the visiting panel that all trainees would feel supported in raising concerns about

either patient safety or their education and training and are encouraged to do so. They would

also be supported to be open about discussing things that have gone wrong.

3.21 Culture & undermining (R3.3)

There were no specific concerns about the culture, or undermining, at the RIE.

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Overall satisfaction

All group of doctors were asked to rate their overall experience of their placement and the

average scores are presented below:

Foundation: Range = 7 - 8, Average = 7 out of 10

CMT: Range = 4 - 7, Average = 5.6 out of 10

ST3+: Range = 5 - 7, Average = 6.3 out of 10.

4. Summary

Overall, the panel felt that this was a positive visit to general internal medicine at the RIE. The

AMU is a busy working environment for trainees but it is clear that trainees enjoy the breadth of

experience on this placement.

Several areas of good practice were identified such as the team-based working/buddying

system, the Master Skills Programme and the newly developed medical ward-based simulation

training.

There are still some areas that require refinement that appear to be ongoing issues from the

2016 visit. Examples of these are the lack of triage within AMU, access to teaching and clinics,

rota pressures impacting on study leave and provision of on the job feedback, particularly in

regard to trainee decisions around their management plans of acute medical admissions.

Aspects that are working well:

• The engagement of trainers and their clear commitment to training.

• The introduction of medical ward-based team simulation training is good practice. We

commended the intention to include scenarios based on incidents reported through the

Datix system. The Deanery note that the simulation training is in its infancy, and that

there were challenges around timing of the sessions.

• There is an engaged and very supportive consultant body, who provide excellent clinical

supervision.

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• There is an impressive array of formal teaching opportunities (although trainees reported

difficulty accessing teaching due to the design of the rota).

• The rota buddy system of having FY1 trainees buddied with FY2 trainees or CMT

trainees on the same shift pattern was noted to be good practice.

• The mastery skills programme supporting clinical skills training for trainees below ST3

level was noted to be good practice.

• The clinical educator programme (CEP) for educator training.

Aspects that are working less well:

• Rota pressures are impacting generally on training. Rota pressures/workload pressures

are a barrier to accessing sufficient formal teaching opportunities for all cohorts, and

access to both study leave and annual leave for CMT trainees.

• Lack of feedback to inform the learning of doctors in training around their management

of acutely unwell patients.

• Insufficient access to clinics for CMT trainees (although we note the introduction of

rostering of clinics for CMTs).

• Lack of clarity around the consultant - and team - ownership of boarded patients.

• A lack of triage within the acute medical unit (AMU) workload was highlighted by trainees

as a potential patient safety issue.

• Handovers are perceived to be safe but we heard about inconsistencies among different

consultants as to how handovers are conducted.

• Departmental induction occurs, but there is no catch up for those who start on nights or

who are on annual leave, the content around roles and responsibilities is variable and

there are ongoing issues around access codes for the ABG machine.

• Lack of specific teaching tailored to the needs of core medicine trainees.

• Lack of a forum for doctors in training to discuss and feedback concerns about their

training.

Is a revisit required?

Yes No Highly Likely Highly unlikely

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5. Areas of Good Practice

Ref Item Action

5.1 The introduction of medical ward-based team

simulation training is good practice. We

commended the intention to include scenarios

based on incidents reported through the Datix

system.

none

5.2 The rota buddy system of having FY1 trainees

buddied with FY2 trainees or CMT trainees on the

same shift pattern.

none

5.3 The mastery skills programme supporting clinical

skills training for trainees below ST3 level.

none

6. Areas for Improvement

Ref Item

6.1 The RIE should consider developing a triage

system within the AMU to prioritise the most unwell

patients to be seen first.

6.2 There should be robust arrangements in place to

ensure the clarity around the consultant - and team

- ownership of boarded patients.

6.3 While handovers are perceived to be safe,

inconsistencies among consultants in how

handovers are conducted should be addressed.

6.4 The barriers to the access of doctors in training to

ABG machine, that relate to provision of access

codes, should be addressed.

6.5 The content of formal teaching provision should be

reviewed to ensure the content also meets the

learning needs of CMTs.

6.6 The lack of understanding among non-medical

staff around the significance and implications of

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different grades of trainees having different colour

coded badges should be addressed. This scheme

is noted to be in its infancy.

6.7 A forum for doctors in training to discuss and

feedback concerns about their training to education

/ training leads should be introduced.

7. Requirements - Issues to be Addressed

Ref Issue By when Trainee cohorts

in scope

7.1 The current rota must be reviewed and revised to

ensure better access to training opportunities,

including formal teaching sessions (with bleep-free

attendance).

21 October

2019

All

7.2 The current rota must be reviewed and revised to

ensure sufficient access to outpatient clinic training

opportunities. We commend the introduction of

rostering of clinics for CMTs.

21 October

2019

CMTs

7.3 The current rota must be reviewed and revised to

address difficulties in accessing study leave and

annual leave.

21 October

2019

CMTs

7.4 Trainers within the department must provide more

regular informal ‘on the job’ feedback, particularly

in regard to trainees’ decisions around their

management of acute medical admissions.

21 October

2019

FY, CMT

7.5 A process must be put in place to ensure that any

trainee who misses their induction sessions (to

hospital and department) is identified and provided

with induction.

21 October

2019

All

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Action undertaken by NHS Lothian to address requirements can be found by logging in to NHS

Lothian’s Medical Education Directorate website. See “Action Plan” – located at the bottom of

the webpage.

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